Medicaid - DME - Guidelines and coverage policies

1.DMEPOS Program coverage areas include parenteral and enteral nutrition (PEN), medical foods and oxygen and oxygen equipment; all of which must meet the definition of durable medical equipment, a prosthetic device, an orthotic device, or disposable medical supply.

2.Durable Medical Equipment (DME) of a medical nature, needed as a result of a medical condition, and which lasts a considerable time without significant deterioration and appropriate for use within the home, is covered by the Division of Health Care Financing and Policy (DHCFP) and Nevada Check Up (NCU) for eligible recipients. Equipment repairs, or replacement requires medical documentation and is subject to limitations of model, cost and frequency, which are deemed reasonable by the program.

3.Disposable medical supplies are covered by the DHCFP and NCU for eligible recipients only if they are necessary for the treatment of a medical condition and would not generally be useful to a person in the absence of an illness, disability or injury.

4.All DMEPOS products and services must be medically necessary, safe and appropriate for the course and severity of the condition, using the least costly and equally effective alternative to meet the recipient’s medical needs.

5.Deluxe equipment will not be authorized when it is determined a standard model will meet the basic medical needs of the recipient. The recipient must have a medical need for each component of the item(s) requested. This includes accessory items and features not included in the standard models of the product.

6.Equipment which the program determines is principally for education or rehabilitation will not be approved.

7.Refer to Appendix A of this Chapter for non-covered services, and for special coverage considerations that are based on medical necessity outside of the DMEPOS Program or that is considered under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Healthy Kids Program.

10.The DHCFP does not reimburse for items that are the same or similar to items that the recipient has already acquired, such as but not limited to back-up equipment, unless allowed in the specific policy for that item. Duplicate items intended to be used within the same span of time are not considered medically necessary.

11.Individuals deemed eligible for Nevada Medicaid or NCU and who have ownership of existing equipment from any prior resource must continue using that equipment. Existing equipment, regardless of who purchased it, must be identified, including the estimated date of purchase or age of equipment, and medical documentation showing evidence of need for replacement. All documentation must be submitted with a prior authorization request.

12.Some items not covered under the DMEPOS Program may be covered under other Medicaid programs such as Pharmacy, Audiology, or Ocular programs. Additional resources may be available through other agencies or through waiver programs for items not covered under the DMEPOS Program or by the Medicaid State Plan.

B.PROVIDER RESPONSIBILITY

1.All DMEPOS providers must be licensed through the Nevada State Board of Pharmacy (BOP) as a Medical Device, Equipment, and Gases (MDEG) supplier, with the exception of a pharmacy that has a Nevada State Board of Pharmacy license and provides DMEPOS. Once licensed, providers must maintain compliance with all Nevada BOP licensing requirements. Reference Medicaid Services Manual (MSM) Chapter 100 – Medicaid Program for further information on enrollment and provider responsibilities. Also refer to the Enrollment Checklist posted on the following website at: https://www.medicaid.nv.gov.

2.Suppliers of products covered under the Medicare Part B program are required to be enrolled in the Medicare Part B program in order to provide those services to Medicare and Medicaid dually eligible recipients. This includes obtaining and maintaining the Centers of Medicare and Medicaid Services (CMS) required accreditation and surety bond.

3.Potential providers who are not enrolled with the Medicare Part B program and who will not be supplying products covered under the Medicare Part B program to

individuals eligible for Medicare are required to provide a statement on/with their application that requests a waiver of the requirements for Medicare Part B enrollment. This statement must indicate that they do not service Medicare-eligible individuals and include a listing of the products they plan to supply.

4.A Medicaid-contracted DMEPOS provider may be reimbursed for services rendered to Medicaid eligible recipients when provided in accordance with established policies, guidelines and timeframes.

5.The provider is responsible for ensuring the equipment is appropriate for the recipient and the recipient’s residence prior to billing the DHCFP.

6.The provider is responsible for providing a manufacturer’s invoice for certain items, where no rate has been established.

3.Present any forms or identification necessary to utilize other health insurance coverage;

4.Contact and return to the provider of services/equipment for any necessary adjustment within the time allotted for such adjustments;

5.Maintain the equipment provided by routinely cleaning and caring for the devices according to user information and supplier’s guidance. Provide safe, secure storage for item(s) when not in use to protect item(s) from loss or theft;

6.Not misuse, abuse or neglect purchased or rented item(s) in a way that renders the item(s) unsafe or non-usable;

7.Return all rented equipment to the DMEPOS provider when no longer being used, or upon the DME provider’s request. Failure to return rented equipment could result in a recipient’s financial responsibility for the retail price of the rented equipment, even if the equipment is lost/stolen, the recipient has moved, or they are no longer eligible for Nevada Medicaid/NCU.

8.Comply with additional requirements as specified throughout this Chapter and its Appendices and MSM Chapter 100.

DOCUMENTATION REQUIREMENTS

A.Supplier/provider records must substantiate the medical necessity for all DMEPOS items dispensed to recipients. The following describes the requirements for specific types of documentation associated with DMEPOS.

1.ORDERS / PRESCRIPTIONS

a.All DME items, Prosthetics, Orthotics, or Disposable Supplies (POS) dispensed must have an order/prescription from the treating physician or practitioner, (To determine included practitioners, refer to MSM, Chapter 600 – Physician’s Services), such as a Physician’s Assistant (PA), or Advanced Practitioner of Nursing (APN), when within their scope of practice and in accordance with federal and state laws governing that entity, prior to dispensing the item.

In accordance with the Patient Protection and Affordable Care Act (PPACA) (The Affordable Care Act) of 2010 (Public Law 111-148), all orders for DMEPOS items, whether verbal or written, must be incidental to a physician-documented face-to-face encounter between the recipient and the prescribing physician/practitioner (as allowed by The Act) within 30 days prior to the start date of the order. The encounter must be relevant to the need for the prescribed DMEPOS.

Refer to Appendix B of this Chapter for additional order requirements on specific products.

General standards of care/practice mandate that if an order is not clear, a clarification of the order must be obtained from the ordering practitioner prior to acting on it.

b.Verbal Orders:

1.Verbal orders from the prescribing physician/practitioner may be accepted for DMEPOS items that do not require prior authorization by the DHCFP (except when Medicare is primary and Medicaid co- payment will be requested, and Medicare requires a written order for that item prior to delivery). Refer online to the DME MAC Jurisdiction D Supplier Manual, Chapter 3 – Documentation Requirements, for a current listing of those items at: https://www.noridianmedicare.com/dme/news/manual/chapter3.html

2.The verbal dispensing order must include:

a.A description of the item;

b.The recipient’s name;

c.The physician’s name;

d.The start date and length of need of the order; and

e.Additional information sufficient to allow appropriate dispensing of the item.

3.Suppliers must maintain written documentation of the verbal order and, if the verbal order is used for dispensing the item, the supplier must obtain a detailed written order prior to billing the DHCFP.

c.Written Orders:

1.Written orders are acceptable for all transactions involving DMEPOS and must be obtained prior to submitting a prior authorization for any DMEPOS items. Written orders may take the form of a photocopy, facsimile image, electronically maintained, or original “pen-and-ink” document.

2.All written orders must, at a minimum:

a.Clearly specify the start date of the order;

b.Include the length of need;

c.Be sufficiently detailed, including all options or additional features that are needed to meet the recipient’s needs. The description must be either a narrative description (e.g., lightweight wheelchair base) or a brand name/model number; and

d.Be signed and dated by the treating physician/practitioner. Signature includes computer signature and pen and ink, no signature stamps allowed.

3.Certain items require additional elements in the written orders, as follows:

a.If the written order is for supplies that will be provided on a periodic basis, the written order must include appropriate information on the quantity used, frequency of change, and duration of need. (For example, an order for surgical dressings might specify one 4x4-hydrocolloid dressing that is changed one to two times per week for one month or until the ulcer heals).

b.If the written order is for an item such as, but not limited to, enteral formula, oxygen, etc., the order must specify the name of the product, concentration (if applicable), dosage, frequency and route of administration, and duration of infusion (if applicable).

c.Custom-fabricated items must be clearly indicated on the written order that has been signed and dated by the prescribing physician/practitioner.

4.There are additional specifications for orders for certain items, such as, but not limited to, Power Mobility Devices (PMDs). Refer to Appendix B for details.

5.The detailed description of the item(s) may be completed by an employee of the ordering physician/practitioner; however, the prescriber must review the detailed description and personally indicate agreement by signing and dating the order.

6.Medical necessity information (such as the most current appropriate diagnosis code(s) (ICD) diagnosis code, narrative description of the recipient’s condition, abilities, and limitations) is not in itself

considered to be part of the order although it may be put on the same document as the order.

d.New Orders Are Required When:

1.There is a change in the order of a specific DMEPOS item;

2.There is a change in the resident’s condition that warrants a change in the order, a change in the treating physician/practitioner, or DMEPOS supplier;

3.An item is replaced for any reason; or

4.An ongoing unchanged order continues to be medically necessary one year after the original order (orders are only valid for up to one year, unless documented with a shorter length of time).

2.DETAILED PRODUCT DESCRIPTION

The detailed product description must contain the Healthcare Common Procedure Coding System (HCPCS) code, manufacturer, make and model, and the provider’s/supplier’s usual and customary charge for each item supplied. The warranty information must also be included. This may be completed by the provider/supplier but must also be signed and dated by the physician.

3.PROOF OF DELIVERY (POD)

A POD is a supplier’s delivery receipt, which is dated and timed.

NOTE: Item(s) ordered must be delivered within 120 days of the date of the order.

4.ADDITIONAL MISCELLANEOUS MEDICAL RECORDS

The recipient’s medical records must contain sufficient documentation of the recipient’s medical condition to substantiate the necessity for the type and quantity of items ordered and the frequency of the use or replacement. The information must include the recipient’s diagnosis and other pertinent information, including but not limited to: duration of recipient’s condition, clinical course (deteriorating or improving), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. The records must include physician’s office records, hospital, nursing home or home health records, records from other professionals including but not limited to: nursing, physical and occupational therapists, prosthetists and orthotists, although

medical necessity for item(s) requested must be stated by the prescribing physician/practitioner.5.ADVANCED DETERMINATION OF MEDICARE COVERAGE (ADMC)

When Medicare is the primary payer, for all items requiring an ADMC (refer online to the DME MAC Jurisdiction D, Supplier Manual, Chapter 9). The ADMC determination must be submitted to the Quality Improvement Organization (QIO)- like vendor at the same time the prior authorization is submitted.

B.PROVIDER RESPONSIBILITY

1.The provider must obtain the required documentation in a timely manner as described under each section listed previously.

2.The provider must maintain records at the physical location of their business for each item billed to, and paid by, the DHCFP for at least six years from the Remittance Advice (RA) date. At a minimum, this includes the original signed order/prescription, all supporting medical documentation, and proof of delivery.

3.The provider must maintain records in a readily accessible location and, for audit and investigation purposes, to make available upon request by Medicaid staff or its contractors, all supporting information related to prior authorizations, dispensed items, and/or paid clams for DMEPOS items.

RENTAL AND PURCHASE OPTIONS

Items identified in the DMEPOS Fee Schedule with a rental and purchase option require prior authorization to determine if the recipient’s needs justify rental or purchase based on the item prescribed, the individual’s anticipated length of need and prognosis (as determined by the prescriber) and cost effectiveness to the DHCFP and NCU.

a.RENTAL

1.In addition to all other requirements and qualifications for specific products, if the DMEPOS Fee Schedule allows a rental option, a device may be rented when:

a.the anticipated length of need (per physician’s/practitioner’s order) is short term (six months or less) and rental would be more cost effective than purchase;

b.a temporary trial period is required for the item according to Medicaid’s policy;

c.the item is only available as a rental per the DMEPOS Fee Schedule; or

d.a temporary rental is needed while a recipient-owned like item is being repaired.

2.During a rental period, rental rates include all supplies and accessories necessary to render the equipment useable and safe, delivery and set up services, education and training for recipient and family, routine maintenance and servicing (such as testing, cleaning, regulating and checking equipment), repairs, non-routine maintenance and servicing (such as breaking down sealed components and performing tests which require specialized equipment and skills of a technician), and replacement of items. These services are the responsibility of the owner, the DMEPOS supplier.

3.Throughout any rental period, there must be an active physician’s/practitioner’s order for ongoing use, the prior authorization effective dates are still applicable, and there is a continued medical need for the item. The DMEPOS supplier must contact the recipient or their representative within five business days prior to each billing cycle to verify the rented item is still medically necessary, in working condition, and being used by the recipient (contact does not include system generated correspondence). Verification must be documented and maintained in the DMEPOS supplier’s records and be accessible for audits.

4.Rent-to-Purchase Option:

a.The DHCFP allows rental of certain DMEPOS items up to the provider’s Usual and Customary Charge (UCC) for purchase, or the maximum Medicaid allowable purchase price of the item; whichever is less.

b.Unless the item is identified by Nevada Medicaid as a rental only, once the total cumulative rental payments have reached the lower of UCC or maximum Medicaid allowable purchase rate, the item is considered purchased in full and recipient-owned.

c.The provider shall automatically transfer the title for the equipment to the recipient. Providers are not to submit prior authorization to transfer titles. Providers are also not to submit prior authorizations coded as a purchase after the lower of UCC or Medicaid allowable purchase rate is reached. No rental or purchase payments will be made for the remaining reasonable useful lifetime of the device (usually not less than five years (60 months)). The provider’s records must include the date the title was transferred to the recipient.

d.When an item was new at the time of issuance, and it is later determined the recipient will need the item long term, rental payments will be applied toward the total purchase rate (either the provider’s UCC or the Medicaid allowable). Refer to “Purchase Used Equipment Option” in Section 1303.

e.Equipment that was not new at the time of issuance, such as items from the provider/supplier rental fleet, supplied as a temporary short term rental item must be replaced with new equipment as soon as it is identified the recipient will need the device long term (no later than in the sixth month of rental). Payments made on rental fleet-type items will not be applied to the purchase price of a new item. Purchase or transfer of titles to recipients when the used equipment is from a rental fleet is not allowed.

f.For this option, non-routine maintenance and servicing or repairs may be covered for service dates after the item is owned by the recipient; no sooner than the month following the last rental month.

5.Rental Only Option:

a.Certain items are identified by Nevada Medicaid as a rental only. For these items, a monthly rental will be allowed as long as the recipient continues to meet all qualifications and requirements, and the recipient continues to use the device.

b.For this option, the DMEPOS supplier retains ownership of the equipment, regardless of the length of rental. As the owner, the DMEPOS supplier is responsible to ensure the equipment remains in safe working condition for the reasonable useful lifetime of the device. The rental rates include all supplies and accessories, repairs including routine and non-routine maintenance and servicing, and replacement of items when needed.
b.PURCHASE

1.Purchase New Equipment Option:

a.Certain products are identified by Nevada Medicaid in the DMEPOS Fee Schedule with a purchase option for new equipment, or can only be purchased, such as disposable supplies and custom-made items which can only be used by that recipient. These will be considered for purchase when, in addition to all other requirements and qualifications for a specific item/device:

1.the anticipated length of need (per physician’s order) is long term (more than six months); and

2.the provider will be supplying a new device/item to the recipient; or

3.the item is only available for purchase.

2.Purchase Used Equipment Option:

a.Certain products are identified by Nevada Medicaid with a purchase option for used equipment. When an item was new at the time it was dispensed to a recipient for rental purposes, and prior to billing the third month of rental, it is determined the item will be needed indefinitely, the DHCFP may purchase the item for the recipient for ongoing use. The DHCFP does not purchase used equipment from the provider’s inventory of rental items used for re-issuance to same or multiple persons over time (rental fleets, etc.).

b.The DHCFP will only purchase used equipment when, in addition to all other requirements and qualifications for the item:

1.the recipient meets the criteria for purchase of new equipment;

2.the item was new when placed in the recipient’s use and has been used for less than three months; and

3.the item is currently being used by the same recipient during a trial period and it has been determined the length of need will now be indefinite.

c.A prior authorization must be submitted to request purchase of a used item, with all supportive medical documentation to show the date the item was initially issued to the recipient and that the recipient continues to have an ongoing need for the item.

PRIOR AUTHORIZATION

A.Prior authorization is a review conducted by the Quality Improvement Organization (QIO)-like vendor’s medical professionals who review the prior authorization form and any additional information submitted to evaluate medical necessity, appropriateness, location of service, and compliance with the DHCFP’s policy, prior to delivery of service. Reference the MSM, Chapter 100 and the general Billing Manual for detailed information on prior authorizations and Medicaid eligibility for all providers at: http://www.medicaid.nv.gov/providers/BillingInfo.aspx.

1.Submission:

a.Prior authorizations must be completed and submitted by a current Medicaid provider (requestor), and the approval must be received, prior to delivery of services. The exception to this is if the recipient is determined eligible for Medicaid retroactively or if number four of this section applies.

c.A Medicaid provider may submit the prior authorization electronically using the QIO-like vendor’s on-line prior authorization system or may fax or mail the prior authorization to the QIO-like vendor. For more information, refer to the prior authorization section posted at: https://www.medicaid.nv.gov.

d.Requestors must submit a prior authorization with the most appropriate HCPCS code available and may not unbundle items included in the HCPCS code description. If an item has a designated code available, the miscellaneous code cannot be used. Providers may contact the Medicare Pricing, Data Analysis and Coding (PDAC) contractor, or the DME MAC for guidance on correct coding.

e.Documentation requirements are the same regardless of which mode of submission is used (e.g. the on-line prior authorization system, faxed, or mailed). Documentation submitted for consideration of the request must include the physician’s order and must clearly support coverage qualifications and recipient’s medical need for the equipment. Failure to provide all of the supporting medical documentation in its entirety, and within the required timeframes, will result in a denial of the prior authorization request, regardless of mode of submission.

f.Unless otherwise stated in policy, a prior authorization may be submitted to request authorization to exceed established quantity limitations when the medical documentation supports medical necessity for the increased quantity or frequency.

2.Review Consideration:

a.In addition to the specifications mentioned previously, for reviewing the prior authorization, products and services must be medically necessary, safe and appropriate for the course and severity of the condition using the least costly equally effective alternative to meet the recipient’s needs.

b.The recipient must have a medical need for, and the requested item must be suitable for use within the home. Consideration will also be based on the recipient’s additional use of the item for the conditions in each of the environments the recipient is likely to encounter in their daily routines, such as, but not limited to: attending school, work, and shopping. This information must be included in the supportive documentation submitted with the prior authorization.

c.For durable medical equipment, prosthetics, orthotics, and disposable medical supplies and appliances where coverage and limitation policies have not been established within this Chapter or its Appendices, the DHCFP may defer to DME MAC Jurisdiction D, Local Coverage Determination (LCD) and policy articles for coverage and limitation criteria. These can be accessed at: http://www.noridianmedicare.com/dme. The item must meet the definition of durable medical equipment, prosthetic, orthotic, or disposable medical supply and must be necessary to meet the medical needs of the recipient, and must be part of the prescribing physician’s/practitioner’s Plan of Care (POC).

d.The DHCFP has the option of requesting an Independent Medical Evaluation (IME) to determine the recipient’s limitations and abilities to support medical necessity.

3.Prior Authorization Requirements for Third Party Liability (TPL) and Medicare Crossovers:

a.Refer to MSM, Chapter 100, for more information on TPL, and Medicare Crossovers and the requirements for securing prior authorizations.

4.Prior Authorization Emergency Situations:

a.In an emergency situation, when an order is received by the supplier after the QIO-like vendor working hours or over weekends or State holidays, dispensing of a 72-hour supply of those DMEPOS items that require prior authorization will be allowed only when:

1.A delay of 24 hours of treatment could result in very severe pain, loss of life or limb, loss of eyesight or hearing, injury to self, or bodily harm to others; and

2.The treating physician/practitioner indicates the most current appropriate diagnosis code(s)/ICD code on the prescription that supports the use of the emergency policy.

b.The provider/supplier must submit the prior authorization the next business day with all required supportive documentation. The documentation must include proof of the date and time the order was received by the supplier and documentation to support both 1303.4(a.)(1.) and (2.).

5.DMEPOS Specific Prior Authorization Forms:

All forms must be completed and submitted by a current Medicaid provider. Forms used must be the most current version.

a.All Forms and Form Release Memorandums or instructions may be accessed at the DHCFP’s website: https://dhcfp.nv.gov/index/htm. The instructions provide detailed guidance on form completion requirements.

b.Specific DME prior authorization forms are found on the QIO-like vendor’s website: https://www.medicaid.nv.gov/providers/forms/forms.aspx. All DMEPOS items that require prior authorization must be requested on these forms and submitted electronically, by fax or by mail to the QIO-like vendor for approval.

c.Usage Evaluation – For Continuing Use of Bi-Level and Continuous Positive Airway Pressure (BIPAP and CPAP) Devices use the form, found on the QIO-like vendor’s website. This form may be completed and submitted for continuing usage of BIPAP or CPAP devices.

d.Mobility Assessment for Mobility Devices, Wheelchair Accessories and Seating Systems, form found on the QIO-like vendor’s website. This form must be submitted for all mobility devices, wheelchair accessories and seating systems.

6.Denied Prior Authorization Requests:

a.There are various processing levels associated with prior authorization requests which do not support medical necessity. These may include, but are not limited to: a contact to the provider by the QIO-like vendor, a system generated technical denial, a system generated denial or reduction of services, a provider-requested reconsideration, a provider-requested peer-to-peer review with the physician. For specific information on time limits and an explanation of each, refer to the general Billing Manual for all providers at: https://www.medicaid.nv.gov/providers/billinginfo.aspx.

b.If a prior authorization request is denied or reduced, the provider and recipient will be sent a Notice of Decision (NOD) with a citation/reason to

provide a general explanation of the denial. The provider may request consideration of the denial by submitting additional supportive information and requesting a “Reconsideration” in writing.

c.If a reconsideration is not appropriate or is also denied, the recipient may be entitled to request an appeal or hearing. Refer to MSM Chapter 3100 – Hearings.B.COVERAGE AND LIMITATIONS

1.Coverage and limitations are explained throughout this Chapter, including its appendices. Appendix B details coverage qualifications, prior authorization documentation requirements, and limitations for specific items.

2.Refer to the Nevada Medicaid Provider Type 33 – DME Fee Schedule posted at: http://dhcfp.nv.gov/RatesUnit.htm for covered services. The Fee Schedule identifies covered services/items (listed in alpha-numeric order according to HCPCS code), and rates. Codes are updated yearly. Codes not included in the fee schedule after the yearly update are considered non-covered.

AMA

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